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Chapter 30: Assessment of the
Cardiovascular System Ignatavicius:
Medical-Surgical Nursing, 10th Edition
Verified and Updated Questions and
Answers (100% Correct Answers)
1. A nurse assesses a client who had a myocardial infarction and has a blood
pressure of 88/58 mm Hg. Which additional assessment finding would the nurse
expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
Answer: ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a
pressure decrease in the vessels. The parasympathetic system responds by lessening
the inhibitory effect on the sinoatrial node. This results in an increase in heart rate
and respiratory rate. This tachycardia is an early response and is seen even when
blood pressure is not critically low. An increased heart rate and respiratory rate will
compensate for the low blood pressure and maintain oxygen saturation and
perfusion. The client may not be able to compensate for long and decreased
oxygenation and cool, clammy skin will occur later.
2. A nurse assesses a client after administering a prescribed beta blocker. Which
assessment would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg.
b. Respiratory rate decreased from 25 to 14 breaths/min.
c. Oxygen saturation increased from 88% to 96%.
d. Pulse decreased from 100 to 80 beats/min.
Answer: ANS: D
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Beta blockers block the stimulation of beta1-adrenergic receptors. They block the
sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta
blocker will decrease HR and blood pressure, increasing ventricular filling time. It
usually does not have effects on beta2-adrenergic receptor sites. Cardiac output may
drop because of decreased HR, but slowing the rate may allow for better filling and
better cardiac output.
3. A nurse assesses clients on a medical-surgical unit. Which client would the nurse
identify as having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma.
b. A 32-year-old man with colorectal cancer.
c. A 65-year-old woman with diabetes mellitus.
d. A 53-year-old postmenopausal woman who takes bisphosphonates.
Answer: ANS: C
Of the options, the client with diabetes has a two- to four-fold increase in risk for
death due to cardiovascular disease. Advancing age also increases risk, but not as
much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the
risk for cardiovascular disease.
4. A nurse assesses an older adult client who has multiple chronic diseases. The
client's heart rate is 48 beats/min. What action would the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client's medications.
d. Administer 1 mg of atropine.
Answer: ANS: C
Pacemaker cells in the conduction system decrease in number as a person ages,
potentially resulting in bradycardia. However, the nurse would first check the
medication reconciliation for medications that might cause such a drop in heart rate,
and then would inform the primary health care provider. Documentation is
important, but it is not the first action. The heart rate is not low enough for atropine
or an external pacemaker to be needed unless the client is symptomatic, which is not
apparent.
Chapter 30: Assessment of the
Cardiovascular System Ignatavicius:
Medical-Surgical Nursing, 10th Edition
Verified and Updated Questions and
Answers (100% Correct Answers)
1. A nurse assesses a client who had a myocardial infarction and has a blood
pressure of 88/58 mm Hg. Which additional assessment finding would the nurse
expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
Answer: ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a
pressure decrease in the vessels. The parasympathetic system responds by lessening
the inhibitory effect on the sinoatrial node. This results in an increase in heart rate
and respiratory rate. This tachycardia is an early response and is seen even when
blood pressure is not critically low. An increased heart rate and respiratory rate will
compensate for the low blood pressure and maintain oxygen saturation and
perfusion. The client may not be able to compensate for long and decreased
oxygenation and cool, clammy skin will occur later.
2. A nurse assesses a client after administering a prescribed beta blocker. Which
assessment would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg.
b. Respiratory rate decreased from 25 to 14 breaths/min.
c. Oxygen saturation increased from 88% to 96%.
d. Pulse decreased from 100 to 80 beats/min.
Answer: ANS: D
, Inquire through: | Professional | Confidential Support
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the
sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta
blocker will decrease HR and blood pressure, increasing ventricular filling time. It
usually does not have effects on beta2-adrenergic receptor sites. Cardiac output may
drop because of decreased HR, but slowing the rate may allow for better filling and
better cardiac output.
3. A nurse assesses clients on a medical-surgical unit. Which client would the nurse
identify as having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma.
b. A 32-year-old man with colorectal cancer.
c. A 65-year-old woman with diabetes mellitus.
d. A 53-year-old postmenopausal woman who takes bisphosphonates.
Answer: ANS: C
Of the options, the client with diabetes has a two- to four-fold increase in risk for
death due to cardiovascular disease. Advancing age also increases risk, but not as
much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the
risk for cardiovascular disease.
4. A nurse assesses an older adult client who has multiple chronic diseases. The
client's heart rate is 48 beats/min. What action would the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client's medications.
d. Administer 1 mg of atropine.
Answer: ANS: C
Pacemaker cells in the conduction system decrease in number as a person ages,
potentially resulting in bradycardia. However, the nurse would first check the
medication reconciliation for medications that might cause such a drop in heart rate,
and then would inform the primary health care provider. Documentation is
important, but it is not the first action. The heart rate is not low enough for atropine
or an external pacemaker to be needed unless the client is symptomatic, which is not
apparent.
